Cesarean births have risen dramatically in recent years, from 22 percent of all births across the country in 1996 to 33 percent in 2008. Although surgical deliveries can be lifesaving for both mothers and babies when they are truly needed, over-use of cesareans is hazardous. Women who have cesareans are more likely to experience delivery complications such as hemorrhage, and are also at greater risk for problems in subsequent pregnancies, including uterine rupture and placenta accreta.

The toolkit targets a specific group of low-risk mothers: women who are pregnant with their first child, when the baby is a full-term singleton (not a twin or other multiple) and is head-down before labor. Cesarean rates for these mothers vary widely across California hospitals, from 12 to 70 percent, suggesting that many hospitals could do better to help these women have vaginal births. The national target rate for cesareans among these mothers is 23.9 percent, which more than half of the state's hospitals exceed.

The new toolkit, which is freely available online, is interesting reading for anyone who is curious about how to tackle such a complex challenge in health care. Its recommendations cover a lot of ground, addressing how to improve the quality of childbirth education, persuade hospital leaders and how to shift payment models so that they reward quality of care and reduce financial incentives for cesareans. There is also a long list of suggestions for how to better support laboring women, such as:

Implement policies that support the physiologic onset of active labor, reduce stress and anxiety for the woman and family, and improve coping and pain management.

Do not avoid or delay placement of epidural anesthesia as a method of reducing risk for cesarean delivery.

Implement intermittent monitoring policies for low-risk women.

Assess fetal presentation by 36 weeks gestation and offer external cephalic version [to turn the baby] to patients with a singleton breech fetus.

"When a woman intends to have a vaginal birth, we can't take that lightly," said toolkit editor Holly Smith, a nurse-midwife and public health researcher with the California Maternal Quality Care Collaborative, in statement about its release. "Insofar as it continues to be a safe option, we need to do whatever we can to protect her wishes."